Transcript

Norman Swan: The latest European country to be struggling with a banking crisis in the Euro zone is Cyprus. Greece is in a mess for different reasons, as are Spain and Italy. And while the media coverage has all been about money and various austerity measures, very few people have been talking about the largely hidden effects on the health of people in those nations.

One person who has been investigating the health impacts is Martin McKee who's Professor of European Public Health at the London School of Hygiene and Tropical Medicine, and what he's found hasn't been liked by those in power, particularly by the Greek government.

Martin McKee: There's been quite a lot of controversy about that, not only in Greece. In fact if you look at the debates among the political leaders, they focus on economic growth and employment and so on, but they've paid very little attention to the impact on the health of their populations.

We've undertaken a number of studies across southern Europe, and what we've seen is that people are being hit very hard in the countries that are worst affected by the crisis. We've published quite a lot of work on this, but when we have we've been surprised by the attempts by people in government and people working for some of the international agencies to find all sorts of excuses for why the data might not be completely up to date or there may be some possible alternative explanation. And yet when we put all of the information together we get a very clear picture of what is happening today that is entirely consistent with what we would expect from the historical research.

Norman Swan: So let's just take it country by country. The worst-case scenarios are really Greece and Spain, aren't they?

Martin McKee: Greece certainly is the worst case. Of course when we talk about this we do need to go back a little bit and look at the causes of the crisis because although the countries are all affected to some extent, the causes are different in each country.

Norman Swan: Because in Greece it's government spending and in Spain it's the banks.

Martin McKee: Well, that's essentially it. In Greece the problem is that the data were fraudulent in fact.

Norman Swan: The economic data or the data on health?

Martin McKee: The economic data were fraudulent and that has been demonstrated very clearly, and there has also been a huge problem in Greece in not collecting tax revenues. So there were specific things that did need to be done economically in Greece. In Spain the situation was quite different because Spain came into the economic crisis with a strong economy, a relatively low level of debt to gross domestic product, and there the problem was the bank failures. The government had to step in to bail out the banks.

What we see in Greece is very severe cutbacks in the health system, which even at the best of times was not functioning terribly well. But we are seeing that facilities are being closed, their opening hours are being reduced, people are finding it difficult to get care. The Greek government slashed the amount of money it was willing to pay for pharmaceuticals and as a consequence some of the drug companies stopped supplying drugs. So people are having difficulty getting their medications. This is particularly true where they need life-saving drugs for cancer and so on. We are seeing a breakdown of the public health system to some extent, the re-emergence of dengue fever and malaria…

Norman Swan: Really?

Martin McKee: Yes. We've also seen increasing numbers of HIV and incidence of HIV among injecting drug users.

Norman Swan: Is this because of closed needle exchanges?

Martin McKee: I think it's primarily related to the impoverishment of groups of the population. There's been an increase in sex work, and linked with that is hazardous drug use, although, again, we don't have a full picture of what's going on because there has been unfortunately far too little research on the health effects of the crisis.

Norman Swan: You were one of the people who did a lot of research when the Berlin Wall fell down, glasnost, and when life expectancy went into reverse in the former Soviet republics. Have we any data yet on premature mortality from Greece?

Martin McKee: No, we don't have it yet. There is some very tenuous evidence that infant mortality has gone up, but we do need to be careful there because it is at a very low level, although we have seen an increase in the last two years for which we have data which we haven't seen for about 20 years. But we need to be careful that this is not just a statistical artefact because of the low numbers, but it certainly is a warning.

But you've raised a very important point because if I go onto the internet now I can get financial data up to the second. I can get unemployment data and economic growth data maybe two or three months afterwards. If I'm looking for health data I'm looking at the situation two or three years ago, and that I think is the most appalling indictment of our political leaders in that they have put so little priority on monitoring the health of their population at a time when the European Union has a treaty commitment to evaluate the health impact of all of its policies. And one of the most important of its policies in Europe at the minute in association with the European Central Bank and the IMF is the austerity package.

Norman Swan: Get your overdraft down, in a sense, and they are pushing that through the Central Bank without measuring the impact.

Martin McKee: That's absolutely right, and of course the money that is going to Greece is largely going straight back out again to pay the banks who lent the money in the first place, it is not there to benefit the Greek people.

Norman Swan: From your experience in Eastern Europe, if there were to be a reversal of life expectancy, how long before you see it?

Martin McKee: It's quite difficult to know because there were particular circumstances in particularly the former Soviet Union that was most badly affected, and that was because mortality there was very heavily driven by the role of hazardous alcohol consumption, and in particular the widespread consumption of the aftershaves, the surrogate alcohols, which are about 95% ethanol, and they were very easily available. So whenever you have a high level of mortality from alcohol you see fluctuations very quickly. Literally you go out, get drunk, drive into a tree and die tonight, whereas some of the health effects of other causes of death or other risk factors like nutrition, smoking and so on can take decades. So if we look historically we can see the effects of the Second World War, Dutch hunger winter, the problems in the Ukraine in Russia, starvation and so on, we can see that after many years but it takes a long time to feed through.

Norman Swan: We're doing this interview in one of the temples of public and population health internationally where for years people here would have said, well, the contribution of curative medicine to life expectancy is maybe only 10%, 90% is public health, therefore while we all like the fact that there are hospitals and doctors and drugs around, what's your estimate of the contribution of life expectancy of curative medicine? Because you hear the stories, the Israeli doctors go on strike and fewer people die.

Martin McKee: We've recently been doing some work looking at the strikes among doctors in Israel, but that's another subject. It's an impossible figure. We've actually done quite a lot of work using what we term amenable mortality as a measure of health system performance, and that uses the deaths that should not occur in the presence of timely and effective care. But we are looking at the final stage, the death that is avoided by healthcare. There are other things upstream that would prevent the condition ever arising in the first place, so I don't think we can put a particular figure on it.

Norman Swan: So what you're talking about here is like seeing your GP and getting put on a cholesterol lowering drug and that sort of thing.

Martin McKee: Exactly, but I think we can also look at statements like the one that you've just made, the one about the contribution of public health from a historical perspective, and it's certainly true that if we were looking before the Second World War, healthcare could do relatively little, and at that time there was a great deal to be done with basic public health measures. Healthcare has changed out of all recognition. So the best estimates suggest that about 50% of the decline in cardiovascular disease over the last three decades has been attributable to healthcare, and the remainder due to other factors. It will vary condition by condition of course.

Norman Swan: So what about Spain? They talk about incredibly high levels of unemployment in youth but also flowing through to the general population. Unemployment is known to be a very strong predictor of lack of health, of illness and disease and premature mortality. What's the story from Spain?

Martin McKee: One of the papers that we did looked at the situation between about 2006 and 2010 in terms of consultations with general practitioners, and we found that there had been a very substantial increase in consultations by people with mental health problems, particularly depression and anxiety. We've also done more recent work looking at changes in suicides, and there does seem to have been a step change at the time of the economic crisis, in particular affecting people living in northern Spain and in southern Spain, but less so in the centre of the country. And that increase is concentrated among men and among those of working ages, which is entirely what you would predict from all of the historical research.

The situation in Spain is certainly not as bad as Greece. We also don't have the more up-to-date data on the impact of the health system changes, but we do have a great deal of information on the cutbacks that are taking place in a number of the regions. Spain has changed its legislation on healthcare recently in a way that I think many of us find quite concerning. In the past it was the situation that anyone who lived in Spain had coverage and then the current government introduced by royal decree, not by taking it through Parliament, a change in the rules that would take illegal migrants out of the health system. A number of the regions who have responsibility for health care have rejected this and have said that they will continue to provide free care…

Norman Swan: Like Catalonia.

Martin McKee: Yes, but there are certainly a number of concerns about the dangers that this might pose, not just for the immigrants but also because of the spread of infectious disease.

Norman Swan: So what's the European community to do or individual governments? What's the intervention when you're facing a financial crisis like this and the world's financial system is coming down on your head?

Martin McKee: Well, there are several ways in which we can look at that question. The first question is; is the austerity policy being pursued improving the economy? And I think now it's pretty evident that it's not. We see this particularly in the United Kingdom. Even those few economists who did support the current government's austerity policy are now questioning it. The International Monetary Fund have reassessed the rule of austerity and are arguing for a reversal of the policies being adopted in the UK and by extension in a number of the European countries.

So we've seen governments adopting austerity policies that are essentially closing off growth and making the situation worse. The economic policies that are being pursued I think are now, by general consent, the wrong ones. Having said that, then what is the European Union to do? Well, we have DG SANCO, which is the Health and Consumer Affairs Directorate, that has a treaty responsibility to look at the health impact of all European Union policies. It should be doing that, it should be doing that now, and it's not doing it. If we look at the documents being published by the troika—the European Union, the European Central Bank and the IMF—health is barely mentioned except where they have requirements to cut back services even more. And amazingly, given everything we know about the effects of austerity, calling for reductions in tuberculosis services in Greece, it is quite amazing.

Norman Swan: It is amazing that we're still having this conversation when you heard of the IMF and even the bank in the old days, the World Bank going into countries and saying, 'You can't have a publicly funded health service, if you want our money you've got to privatise healthcare,' when we know that healthcare doesn't work in the private market.

Martin McKee: Well, we do know that private healthcare doesn't work in a private market, and of course now we're seeing much more of the evidence of that. Essentially the problem that we now face, which is even greater of course in the high income countries than in the low income countries where the debate is taking place, is that in countries like Australia, the United Kingdom, European countries, the challenge is that of an older population, an ageing population with multiple complex chronic diseases. And yet time after time the financial sector is telling us that markets hate uncertainty, and those people and their health needs are, by definition, uncertain.

So if you get extensive private provision, those providing the care have every incentive to take those people out of what they do and leave them to the state which will then pay all the bills while they collect the profits on young healthy people. So you see increasing numbers of advertisements for scanners and for…well, as you know in Australia recently, the debate about prostate screening. And all sorts of investigations to find things that young healthy people have got that will probably never do them any harm but can be treated at a profit. And at the same time the older people with complex diseases will be squeezed out of the system.

Norman Swan: And you've done some analysis on the impact on the elderly.

Martin McKee: Well, we've been looking at the changes that have been taking place in the United Kingdom in terms of the economic situation of older people. We're seeing unfortunately at the present time the austerity policy driven by ideology. It's transferring the cost of providing services from the collective, the people as a whole, to the individual. The cost of providing the services, if it's not organised collectively, will be much more expensive as the individual has to do all the work and doesn't have the purchasing power and so on. We're seeing a policy of divide and rule. Statements by ministers are attacking immigrants, forgetting the fact that much healthcare in this country is provided by migrants, it's not that the migrants are taking away the healthcare, they are the ones in many cases who are actually delivering it.

Norman Swan: Nigerian nurses?

Martin McKee: Well, and in fact doctors from all over the place, nurses from many countries. So we desperately need migrants to be able to deliver healthcare. But also we're seeing increasing attacks upon the elderly, and this is part of an attack on universalism. We're being told that the baby boomers have never had it so good, that they are stealing money from future generations. We hear cabinet ministers saying this quite regularly. So a number of measures are being put in place that will undermine the benefits they have.

We have one of the worst state pension schemes in Europe. Our pensioners are among the poorest in Europe, the government is unwilling to address some of the problems that are causing that, in particular we have a large private pension industry where the returns on investment are absolutely abysmal. In fact we are one of the three countries in the European Union where the net return that people achieve from investing in private pension funds has been negative over the last 10 years because the financial services sector takes such enormous fees from managing the funds. Very different from the situation in countries like the Netherlands or Denmark or elsewhere.

We also have an attack on some of the welfare benefits that older people have, and although the government is maintaining them for the time being, things like free bus passes are under threat, which would be unfortunate in many ways because we know that one of the things that keeps older people healthy is being engaged, able to go out.

Norman Swan: Martin McKee is Professor of European Public Health at the London School of Hygiene and Tropical Medicine.

Now, we've had a strong response to last week's Health Report on the failure of the federal government to drive generic drug prices down to the level achieved by other countries. One result of this is an unnecessary drain on health funding, but the other is increased out-of-pocket costs for consumers. Here are two of the emails I got during the week.

One says: 'I have been taking Warfarin for 20 years after an aortic valve replacement. Since then I have lived in several states and experienced a little bit of price difference, but recently I was asked to pay double, $17 out-of-pocket for a bottle of 50 2mg-tablets. I drew the pharmacist's attention to this and she replied that there was no way that she could reduce it. I have shopped elsewhere and now obtain it at the more reasonable rate of $8.50. My point is that I was lucky that I am mobile enough to shop around. The time is long past,' says the writer, 'when the pharmaceutical industry and the government bodies who administer it are due for a shake up.'

And another listener writes: 'I listened with interest to your program today about the pricing of generic drugs. Call me naive, but I thought the purpose of generics was to offer an identical product to the original off-patent product at a discounted price. I am on a lifetime daily dose of Latanoprost for the control of glaucoma. The 'brand' product is Xalatan, which I purchase monthly. However, my recent experience in three pharmacies is that the generic they offer is not cheaper at all compared to Xalatan in terms of my out-of-pocket costs—they are all sold at $36. Is this simply profiteering by the pharmacies or is it linked to government pricing policies for this generic? I can get a different branded generic at a more distant 'discount' pharmacy for $25. Perhaps I need to start challenging my pharmacist to match that price, but I thought the pricing on prescription drugs was somehow under greater control by the PBS. Seems that was misguided.'

You've been listening to the Health Report, I'm Norman Swan, and I'll see you next week.

Guests

Professor Martin McKee

Professor of European Public HealthLondon School of Hygiene and Tropical MedicineLondon